Skydiving Registration Form

Full Name ADDRESS POSTCODE EMAIL PHONE Date of Birth Weight (max 16st) Age on date of jump Medical conditions Alternative Recent or recurring injury Yes / No or on medication

Height Preferred jump date

Yes / No

CHARITY SKYDIVING TERMS By taking part in a skydive in aid of The Prince of Wales Hospice you are bound by the following terms and agree: 1. To aim to meet the minimum fundraising target set by the charity, otherwise you will cover the remaining amount yourself and/or pull out of the event and refund all monies to the sponsors. 2. To make every effort to exceed the minimum target 3. To send on any additional funds raised directly to the charity within the timeframe agreed. Failure to do so is considered theft. 4. To make clear to sponsors if you are not paying for the skydive yourself and that the cost will be covered with their donations. 5. That your contact details will be passed on to the charity and the skydiving centre. They will not be passed on by us to any other third party for any reason. 6. Skydiving is an adventure sport and participation involves a risk of injury or death and you voluntarily accept all the risks inherent 7. That the organiser/ charities will not accept any liability or responsibility for you taking part in a skydive.

I have read and agree to the terms above. I am aware of the age, weight and medical restrictions for the skydive
(print name)........Signed.Date How to pay your deposit: Please post this completed form with a cheque for your deposit payable to The Prince of Wales Hospice to Skydive, The Prince of Wales Hospice, Halfpenny Lane, Pontefract WF8 4BG Please email this form to : fundraising@pwh.org.uk and call the team on 0844 2484 787 to pay over the phone Contact Fundraising: Tel: 0844 248 4787 Mail: The Prince of Wales Hospice, Halfpenny Lane, Pontefract WF8 4BG If you need any information about the skydive itself or the age, weight and medical restrictions then you can contact Skydive Hibaldstow directly on telephone number 0113 250 5600 or email info@skydiving.co.uk

Thank you for choosing to support The Prince of Wales Hospice